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一项关于减少急诊科计算机断层扫描使用的干预措施的系统评价。

A Systematic Review of Interventions to Reduce Computed Tomography Usage in the Emergency Department.

机构信息

Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.

Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.

出版信息

Ann Emerg Med. 2022 Dec;80(6):548-560. doi: 10.1016/j.annemergmed.2022.06.001. Epub 2022 Aug 1.

Abstract

STUDY OBJECTIVE

Unnecessary computed tomography (CT) scans burden the health care system, leading to increased emergency department (ED) wait times and lengths of stay, costing almost a billion dollars annually. This study aimed to describe ED-based interventions that are most effective at reducing CT imaging while maintaining diagnostic accuracy and patient safety.

METHODS

Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and Google Scholar were searched until December 31, 2020. Randomized and nonrandomized studies that assessed the effect of an ED-based intervention on CT scan usage were included. Abstract screening, data extraction, and quality assessment were conducted in duplicate. The Grading of Recommendation Assessment, Development and Evaluation framework, with the Risk of Bias 2 and Risk of Bias in Nonrandomized Studies - of Interventions tools, was used to determine the certainty of evidence. Significant clinical and statistical heterogeneity precluded meta-analysis; hence, a narrative synthesis was conducted.

RESULTS

A total of 149 studies were included of 5,667 screened abstracts, with substantial interrater reliability among reviewers (Cohen's κ>0.60). The CT reduction strategies were categorized into 15 single and 11 multimodal interventions by consensus review. Interventions that consistently reduced CT usage included diagnostic pathways, alternative test availability, specialist involvement, and provider feedback. Family/patient education, clinical decision support tools, or passive guideline dissemination did not consistently reduce usage. Only 44% of studies reported unintended consequences of reduction strategies; however, these showed no increase in missed diagnoses or patient harm. The interventions that engaged multiple specialties during planning/implementation had a greater reduction effect than ED only. The certainty of evidence for the primary outcome was very low.

CONCLUSION

Multidisciplinary-led interventions that provided an alternative to CT imaging were the most effective at reducing usage and did so without compromising patient safety.

摘要

研究目的

不必要的计算机断层扫描(CT)检查给医疗保健系统带来负担,导致急诊部(ED)等待时间和住院时间延长,每年花费近 10 亿美元。本研究旨在描述在保持诊断准确性和患者安全性的同时,最有效地减少 CT 成像的 ED 干预措施。

方法

根据系统评价和荟萃分析的首选报告项目指南,检索 MEDLINE、Embase、CINAHL、Cochrane 对照试验中心注册库和 Google Scholar,检索时间截至 2020 年 12 月 31 日。纳入评估 ED 干预对 CT 扫描使用影响的随机和非随机研究。进行了摘要筛选、数据提取和质量评估。使用推荐评估、制定和评估框架(Grading of Recommendation Assessment, Development and Evaluation,GRADE),以及非随机干预研究的风险偏倚 2 工具和风险偏倚工具,来确定证据的确定性。由于存在显著的临床和统计学异质性,因此无法进行荟萃分析;因此,进行了叙述性综合分析。

结果

共纳入 149 项研究,其中包括 5667 项筛选摘要,评审者之间的一致性非常高(Cohen's κ>0.60)。通过共识审查,将 CT 减少策略分为 15 种单一策略和 11 种多模式干预策略。一致减少 CT 使用的干预措施包括诊断途径、替代测试的可用性、专家参与和提供者反馈。家庭/患者教育、临床决策支持工具或被动指南传播并没有一致减少使用。只有 44%的研究报告了减少策略的意外后果;然而,这些并没有增加漏诊或患者伤害。在规划/实施过程中涉及多个专业的干预措施比仅在 ED 中实施的干预措施具有更大的减少效果。主要结局的证据确定性非常低。

结论

多学科主导的干预措施提供了 CT 成像的替代方法,是最有效地减少使用的方法,而且不会影响患者的安全性。

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